North Carolina health insurance

NC leadership opposes reform, but exchange is working

Despite the fact that much of the political leadership in North Carolina has been opposed to healthcare reform, the state has been touted as one of the most successful HHS-run exchanges, and hundreds of thousands of people gained coverage during the 2014 open enrollment period. Public health and access to quality health care play a significant role in long term health outcomes and quality of life.

Here’s a summary of North Carolina residents’ overall health, access to health insurance, and the state’s approach to healthcare reform:

America’s Health Rankings concurred, ranking North Carolina 35th out of the 50 states in 2013. The state’s rating is aided by a low incidence of binge drinking, air pollution levels that have decreased by 34 percent in the last five years, high immunization coverage among children, and a correspondingly low rate of pertussis infection. But the state also faces a variety of public health challenges, including high prevalence of Chlamydia and Salmonella, high rates of low birthweight and infant mortality, and relatively few available dentists.

Trust for America’s Health also analyzed public health data in North Carolina in their 2014 edition of Key Health Data About North Carolina, which provides information on several specific diseases and health factors.

The Robert Wood Johnson Foundation’s county rating map for North Carolina lets you see how the counties in the state rank against one another based on a variety of health factor and outcome metrics.

North Carolina and the Affordable Care Act

In 2010, North Carolina’s U.S. Senators were divided on healthcare reform. Kay Hagen, a Democrat, voted yes on the ACA, while Richard Burr, a Republican, voted no. In the U.S. House, five Republican Representatives from North Carolina voted no, while eight Democrats voted yes. Hagen and Burr are still in the Senate, but the U.S. House now includes just three Democrats from North Carolina, and nine Republicans.

Governor Pat McCrory took office in January 2013, becoming the first Republican governor of North Carolina since 1988. His predecessor, Governor Bev Perdue, had stated that North Carolina would enter into a partnership exchange with HHS, but shortly after he took office, McCrory announced that the state would default to a federally-facilitated marketplace.

In addition, MrCrory also decided that the state would not move forward with Medicaid expansion, citing a problematic recent audit of the state’s existing Medicaid program, and noting that the program’s issues needed to be fixed before the state considered expanding it.

McCrory is not a fan of the ACA, but early in the 2014 open enrollment period, he softened his stance a bit in a public announcement to the state’s residents. While he still noted that he was opposed to the ACA, he provided information and resources to help direct people to Healthcare.gov and enrollment assisters.

In general however, the state’s government has taken a largely hands-off role in terms of promoting and implementing the ACA in North Carolina. But a strong network of community-based public health workers, navigators, and volunteers resulted in North Carolina having the fifth-highest exchange enrollment in the country by the end of the first open enrollment period.

How did the ACA help North Carolina Residents?

In 2013, the uninsured rate in North Carolina was 20.4 percent; the Tar Heel State was one of fourteen states with more than a fifth of their population uninsured prior to Obamacare implementation in January. That number has since fallen by nearly four percentage points.

But 16.7 percent of North Carolina residents were still uninsured in mid-2014, six months after full Obamacare implementation. North Carolina’s refusal to expand Medicaid has resulted in an uninsured rate that is considerably higher than it would be if the state had accepted federal funds to make Medicaid available to all legal residents with incomes up to 138 percent of poverty.

But the ACA has certainly benefitted the 431,000 residents who used the exchange to enroll in Medicaid or private plans during the first open enrollment.

North Carolina enrollment in QHPs

The Kaiser Family Foundation estimated in late 2013 that 1,073,000 North Carolina residents could potentially buy coverage through the exchange, and that 684,000 of them would qualify for premium subsidies. By the end of the first open enrollment period, 357,584 people had purchased plans through the exchange in North Carolina, with 91 percent of them receiving premium subsidies.

Two carriers are offering policies in the North Carolina exchange in 2014: Blue Cross Blue Shield of North Carolina, and Coventry Health Care of the Carolinas. But United Healthcare will be joining them in 2015, adding some much-needed competition to the state’s exchange and providing more options for customers; in 61 of the state’s 100 counties, only one carrier was available in 2014.

North Carolina Medicaid/CHIP enrollment

North Carolina is currently one of 22 states that has not yet expanded Medicaid and has no pending plans to do so. The ACA would have expanded Medicaid to cover all legal residents with incomes up to 138 percent of poverty, but in 2012 the Supreme Court ruled that states could opt out of Medicaid expansion, and Governor McCrory has thus far refused expansion.

He has said that it would be unwise for the state to expand Medicaid in light of a recent audit that uncovered fraud and waste in the state’s Medicaid system, but he left the door open for the possibility of Medicaid expansion in the future, as well as a possible switch to a state-run exchange, “if it becomes clear that the current course of action is not the best interest of North Carolina, our health care system and our citizens.”

Most experts agree that states like North Carolina will eventually expand Medicaid simply because of economics – the lure of reducing uncompensated care on a local level via funding that is almost entirely from the federal government will likely make a case that’s too strong to resist. But it could be several years before all of the states get on board.

By mid-April, 73,898 people had enrolled in North Carolina’s existing Medicaid program through the exchange, although another 318,710 could have potentially enrolled if the state had expanded coverage in 2014. For now, enrollment in 2014 is still contingent on North Carolina’s existing eligibility guidelines: Non-disabled adults without dependent children cannot enroll no matter how low their income is, and parents with dependent children are only eligible if their household income doesn’t exceed 45 percent of poverty (a little over $742/month for a family of three).

Because the state refused to expand Medicaid, North Carolina has 318,710 people – about 28 percent of its uninsured population – in the coverage gap, with no access to Medicaid or exchange subsidies. These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But in 2014, there are no realistic insurance options available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing guidelines.

Does North Carolina have a high risk pool?

Before the ACA dramatically reformed the individual health insurance market, coverage was underwritten in nearly every state, including North Carolina. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions. The North Carolina Health Insurance Risk Pool was created in 2009 to give people an alternative if they were unable to obtain individual health insurance because of their medical history.

When ACA implementation resulted in a guaranteed issue individual market in January 2014, risk pools were no longer necessary. The North Carolina Health Insurance Risk Pool ceased operations at the end of 2013, and members were able to transition to new, ACA-compliant plans issued on or off-exchange.

State-based health reform legislation

North Carolina passed a law in 2013 prohibiting the state from establishing a state-run or partnership exchange, and also rejecting Medicaid expansion under the ACA. The state legislature has also had a variety of other health and healthcare reform bills in the 2014 session. Here’s a summary: